Grace & Peace Benevolence Application Form

Please fill out this application as best as you can so that we may learn more about you and your needs.

Name

First Name Last Name

Today's date

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Month
-
Day Year

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number

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Area Code Phone Number

E-mail

What is the best way to contact you?

Amount of money requested:

Date the money is needed by:

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Month
-
Day Year

Please use the space below to describe your current situation and the assistance you need. Please provide all relevant details, including when this need started, if it is a one-time request or recurrent need.

Family Information

Marital Status

Married Single

Do you have children?

Yes No

What are your children's ages?

Are there other people who are part of your household?

Do you have any extended family in the Austin area?

Employment Information

Are you currently employed?

Yes No

Employer Name

Employer Contact Information

Name and contact of person filling out this form if not recipient:

If you are filling this form out on behalf of someone and are part registered 501(c)3, please provide a copy of your determination letter here.

INELIGIBLE REQUESTS

Credit card debt

Automobile purchase

Long-term or recurring expenses

Cash

By signing this document I acknowledge and agree to the following statements: If requested, I will provide documentation regarding my income, expenses, and/or bank accounts.-I authorize Grace and Peace Austin (G+P) to review and share any information in the document or otherwise provided as necessary for the purpose of evaluating my request for assistance.-I understand all checks are issued directly to the vendor for rent and utilities. In emergency cases (if applicant is facing eviction or utilities are being turned off, etc.) applicant can pick the check up from the church office.-I understand an applicant will only be helped once every 12 months unless there are extenuating circumstances and the Committee approves the exception.-I promise to notify G+P of any funds or help I receive from other sources regarding this request.-I promise to use the aid I receive from G+P in connection with my request for assistance solely for the purposes I have described in this document.-I understand that G+P has the right at any time, and in its sole discretion, to deny a request for assistance, to provide non financial assistance rather than financial aid, and to change or terminate any type of aid it chooses to provide.-I understand that G+P does not discriminate on the basis of race, color, sex, national origin, age, disability, relationship with anyone in the leadership of G+P, or financial contributions to G+P.